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?0.�• �? SAN JOAQUIN COUNTY EIVED <br /> h: <br /> }:w QOM ENVIRONMENTAL HEALTH DEPARTMENT Return this for by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 , nn pp 12th of each month <br /> • ''+faa� , VIRONMENT Telephone: (209) 468-3420 Fax: (209)464-0138 Web_www.sjgoV1Q/e0 ` <br /> pEgV' SEPTAGE CLEANER'S REPORT ENVIRONMENTAL HEALTH <br /> Company Name: Report for thm th of: { year <br /> Company Address: Signature: <br /> Street Address City Zip Code <br /> All information submitted must be Com lete, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PLEASEINCLUDPUMPED (G) GREASETRAP FACILITY <br /> /^ E STREET p, DIRECTION, STREET NAME AND CITY C) CHEMICAL <br /> V <br /> Cit <br /> QN L 1 Q t 0 f L( t1 <br /> t( �"� c ity LA C c b <br /> t <br /> rIdt t <br /> LA V( CI L` )6 d LI <br /> Lt ([ cit 60 L� <br /> city LA j 0Q) L.( <br /> ` city 'D yr AL <br /> Cii <br /> v r>� ( ; t <br /> -� Ci � o <br /> Cit <br /> X <br /> 'l city <br /> )(J / Cit �1 V Lk <br /> /0 I -' ��� J� (P (t���h ] J ►/C. l U L l (� Page of <br /> EHD 42-04 <br /> 12/27/13 �` C t L ^SEPTAGE CLEANERS REPORT <br />